Contract Monitoring Report
Provider: Lansdowne (Four Seasons)
General Information about the Organisation
Registered Provider: / Four Seasons HealthcareRegistered Address: / Lansdowne Care Centre
Service address: / Claremont Road, Cricklewood, London, NW2 1TU
Registered Manager: / [Name Withheld]
Name of Person Representing the Provider: / [Name Withheld]
Provider Telephone Number: / 0208 8308444
Provider email address / [Contact Details Withheld]
Service email address /
Provider website / / Does the website shows how to make a complaint / Yes
Does it provide a link to most recent CQC report / Yes
Most recent CQC inspection summery / Date / 30.July.2015
Overall rating / Good
Safe / Good
Effective / Good
Caring / Good
Responsive / Good
Well lead / Good
Is the CQC inspection summery displayed in colour & easily visible/ easy read (applies post April 2015 only) / Yes
Monitoring Date: / 28/4/2016
In attendance: / 1.[Name Withheld]
2.[Name Withheld]
Insurance Details
Public Liability: LC COM 6825457 /Amount: £ 10M
/ Expiry Date: 30.12.2016Employer Liability: LC COM 6825457 / Amount: £5M / Expiry Date:30.12.2016
Professional Indemnity: / Amount: £ / Expiry Date:
Number of / Compliments/ Complaints / Incidents / Accidents / Safeguarding Concernsin the last six months
Number of safeguarding concerns raised / <5Number of formal compliments received / 11 – various cards and letters
Number of formal complaints received / <5
Number of Service users as at date of monitoring visit / 79
Any current vacancy / Approx 8 – status of 2 rooms unclear if available in future
Number of staff as at date of monitoring visit (Provide a breakdown for 24 hrs including management cover)
Number of accidents / 21
Number of incidents / 13
Record of / Complaints / Incidents / Accidents / Safeguarding concerns in the last six months
Action taken/outcome
Are there any OPEN complaints
<5 complaint open – [3rd party personal information withheld]
Any open Incidents /Accidents that currently being investigated
(Date/Time/initials of service user/type
e.g falls)
None
Any open Safeguarding Concerns (information from LBB safeguarding team and cross referenced with provider)
<5 safeguarding case open – relating to pressure care
Any trends identified
Complaints (e.g. food, clothing, staffing, call bells…)
No specific trends noted – most complaints relate to laundry, meals and other day to day occurrences
Incidents/ accidents (e.g.time/person/type…)
No trends noted
Safeguarding concerns (e.g. Pressure ulcers, finance, physical/emotional abuse…)
No trends noted
- SERVICE USERS FOLDERS (up to 10% of the total occupancy)
Service User initials / Is the file organised e.g. indexed, loose papers etc. / How often are the care plan reviewed
(last date of review) / How often are the risk assessment reviewed
(last date of review) / DNAR-CPR
(if in place fully completed) / Power of Attorney- if ‘YES’ Photocopy available / Service user life stories present (Y/N) / Up to date photo of client and date of the picture taken / Next of Kin details
[Initials Withheld] / Yes indexed at front and organised / Monthly / Yes / No / Yes / Yes but not dated / Yes
[Initials Withheld] / Yes / Monthly / No / No / Yes / Yes / Yes
[Initials Withheld] / Yes / Monthly / Yes / No / Yes / No photo seen in file / Yes
[Initials Withheld] / Yes / Monthly / No / No / Yes / Yes / Yes
[Initials Withheld] / Yes / Monthly / Yes / No / Yes / Yes and dated / Yes
- QUALITY ASSURANCE
Service users- 10% of the total no of service user feedback to be evidenced
Date of completion: March 2016
List of evidence the Provider has an effective Quality Assurance system in place – e.g. questionnaires, annual surveys, telephone conversations:
Topic / Covered in the QA questionnaire (Y/N)
- Feel homely
- Feel supported e.g. listen to, personal care
- Food/Nutrition
- Activities
- Complements /Complaint
- Community access
- Finances management
- Are significant changes been communicated to Service users?
- Results and actions completed
Any actions identified following the review:
Staff – 10% of the total no of staff feedback to be evidenced
Date of completion: March 2016
List of evidence the Provider has an effective Quality Assurance system in place – e.g. questionnaires, annual surveys, telephone conversations:
Topic / Covered in the QA questionnaire (Y/N)
- Are they anonymous
- Do staff feel supported
- Training & development needs
- Do staff feel enabled to speak and voice opinions
- Results and actions completed
Any actions identified following the review:
Family members/ Stake holders10% of the total no of staff feedback to be evidenced
Date of completion: March 2016
List of evidence the Provider has an effective Quality Assurance system in place – e.g. questionnaires, annual surveys, telephone conversations:
Who has received Questionnaires e.g. family, GP, Social worker etc.
Family members
Topic / Covered in the QA questionnaire (Y/N)
- Feel homely
- Feel supported e.g. listen to, personal care
- Food/Nutrition
- Activities
- Complements /Complaint
- Responsiveness e.g. communication
- Community access
- Finances management
- Are significant changes been communicated to Service users?
- Results and actions completed
Any actions identified following the review:
Does the provider undertake unannounced visits to the service (Y/N)
Yes
Day/Night/ week ends / Only day time visits noted at different times
How often / Monthly visits by Area Manager
If ‘Yes’ provide Evidence with the action plan
Did not review- manager to forward copy of responses and analysis
Does the provider seek exit surveys when staff/ service users leave (Y/N)
Yes but did not see any evidence
If ‘Yes’ provide Evidence with the action plan
No evidence
What other forms of communication e.g. newsletter, staff/residents/ family meetings
No evidence
Results and actions completed
No evidence
Any actions identified following the review:
- Business Continuity Plan
Last review date / 16th November 2015
Topics / Included in the Business Continuity plan (Y/N) / Actions/Comments
- Loss of heating
- Loss of water
- Loss of lighting
- Faulty lifts
- Fire
- Extreme weather
- No access to this building?
- Lack of staff
- Contagious illnesses
- Pest infestation
- Sudden death
- No Registered Manager in place
Evidence of Contact details for London Borough of Barnet / Yes
Evidence of Contact details for CQC / Yes
*Take copy of providers business continuity plan please attach to the form
- Information Management
- Is there a policy on Data Protection and Data Security? (Y/N)
- Date Last updated
*Obtain a copy of providers policy and send to LBB information management office to review
What visitor access controls do you have in place?
CCTV located in the front car park area and in the reception area; locked front doors
Sign in/out book available and used (Y/N) / Yes all visitors are directed to sign the visitors book
Personal Data
Is personal data stored securely (Y/N) / yes
Is there a policy for access codes (Y/N) e.g. front/back doors / Yes
How often are access codes changed?
There should be evidence that these are changed at regular intervals. They should also be changed each and every time a member of staff leaves. It is logged anywhere in a register to confirm an audit of when it was done last? / [Withheld – prevention of crime]
Seek confirmation as to how they dispose of personal data.
e.g. Do they have a shredder? Or do they have a company that securely destroys their information and they get a certification of destruction? / Shredders are used at the service – archived documents are also sent to Head Office for destruction
General paper handling processes
Observe the home that they are attempting to work in a paper light way and are ensuring paper information is not let lying around in sight of visitors and residents. For example do they have lockable cabinets etc. / Home is moving closer to logging more and more documentation online – information is backed up centrally
Have you had any data security incidents within the last year.
Depending on the response here may be an issue around non-reporting if they highlight something you weren’t previously aware of. Again the officer can take notes and if they are unsure of seriousness of it they can advise the Care Home that we may need further information at a later date to seek assurances. We can review back in the office. / No
- HEALTH AND SAFETY
Fire
Fire drills – Are they carried out in day/ night / Yes – various times of the day and night
Building plan available and visual/ easy access / Yes – viewed in fire log folder
Weekly fire check records & evidence the checks are carried out regularly / Yes
If any faults identified have they been followed up / Yes – reporting channels within the home are clear
Fire system & equipment maintenance records
(needs to be annual checks) / Yes
Fire risk assessments – reviewed annually / Yes
Are the staff informed about the policy & risk assessments / Yes
If any actions from annual risk assessments are they followed up / Yes
Yearly Portable Appliance Testing up to date-
Date of the test / Yes – viewed certificate folder which includes up to date tests for all areas, equipment, lifts, gas, water, pest control etc
Periodic Electrical Installation Conditions Report
Minimum Five Yearly Certificate. Normally completed by certified electrician / Certifacte date April 2014
Are the fire doors clear from obstructions / Yes
Has there been a local fire brigade inspection
Date :
Outcome / Yes
December 2015
No actions
Lone working
Is there a lone working risk assessment – Last date of update / Yes
Are the staff informed about the lone working policy & risk assessments / Yes staff will sign to confirm attendance
Personal Protective Equipment (PPE)
Does home provider Gloves, Aprons, Hand gel/wash, Paper towels etc. / Yes care does provide all suitable equipment
Hand washing facilities available in each rooms - if ‘no’ does the staff carry/use hand gel / Yes
Accident/ incidents
Does the home use an accident book / Yes
Does the home aware of RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) / Yes
Does the home display Health & Safety Law poster and the named person completed / Yes manager and deputy are named as the main contacts on the poster
Number of accidents for the last 12 months / 21
Number of reportable accidents under RIDDOR for the last 12 months / <5
Are there any trends noted/ any lessons learnt and actions taken / Falls is the only trend noted – care home in touch with CCG colleagues and The falls clinic to review and improve management of falls
Building-
Does the home carry out monthly H&S audits – date of last audit
Any outstanding actions from the audit/s
e.g. areas covered includes wheelchairs, bed rails, suction machines etc. / Several audits viewed in managers office – H & S audit March 2016
Review Building Maintenance records. Work completed in a timely manner / Yes – requests for maintenance work are sent to the manager
Trends/ maintenance issues identified and actioned / Routine diy tasks and small repairs to be actioned
Who owns the building and responsible for maintenance
& up to date
Does the provider has a service level agreement in place / Four Season HC – several agreements with various contractors who provide maintenance work and checks on the premises.
Are there any planned maintenance work scheduled for the next 12 months. If ‘Yes’ what / None apart form routine room refurbishment
Annual Gas safety certificate – Certificate date / April 2016
Annual Legionella testing certificate - Certificate date / 16/4/2015
Regular water temperature checks up to date / Not reviewed
Has the home carried out an asbestos survey – date of the survey / July 2013
Windows/ Doors
Do all the windows have a window restrictor fitted - that meet with the Health and Safety Executive guide. / Yes
Appearance of the windows
e.g. Windows and frames and free from rot, able to see through/ clean / Double-glazing throughout the property seem in good condition
Security
What security is available at the home? List… / [Withheld – Prevention of Crime]
Does the home use CCTV (Y/N)
If ‘Yes’ please complete below
Where CCTV installed: / [Withheld – Prevention of Crime]
Have signs up in the home making people aware using CCTV / No
Does the home have a robust and secure system to maintain CCTV footage? E.g. how is this information recorded/ systems and protection are in place? How long are CCTV details kept? Who has access to them? / [Withheld – Prevention of Crime]
Medication/ treatment room
Medicine room and medication cupboard/ fridge locked / [Withheld – Prevention of Crime]
Nurse in charge or most senior staff on duty hold keys (Y/N) / [Withheld – Prevention of Crime]
Medication room/ fridge temperature recorded daily (Y/N) / Viewed sheets which record fridge temperatures daily
General appearance of the room
e.g. Room looks clean and is clutter free,
Flooring is wiped clean and not ripped.
Walls have no chips, infection control issue
If room has window does this have a lock and blind?
Medicine trolley is attached to the wall / Room seems in reasonable order. Some boxes and folders which seem not to be used – can be cleared to avoid clutter
First aid box (Please carry a random check to see if the contents are within dates)
How many and where they are located / Inspected 1 box in reception area.. deputy confirmed that several exist around the care home, unsure what number
Regular audits carried out- how frequent? / Reported that audits are carried out but no evidence of this
Other medical emergency equipment
What other medical equipment available within the home. / Hoist
Bath hoist
Suction machines / Weighing scales
Stand aids
Slings
Are they checked annually/ six monthly (as for the manufacturer’s instructions) / All equipment is checked during regular H&S audits which are carried out
Is there a system in places for clinical waste disposal e.g. Yellow bag, Sharpe box / Sharpes and yellow bag collection happen regularly during the week –
Who the contract with? / Did not check – to ask from manager
How often are they collected? E.g. See the contract / approx. 2-3 times each week
Grounds
Suitable for people to access e.g. ramp/ hand rails etc. / Garden area is very well kept and appealing
Tidy and fit for purpose / Seems like a welcoming area for residents and families to use
Kitchen and Food safety
Kitchen appearance – clean/ are they free from dirt, odour / Kitchen viewed and was busy during my walkaround. Surfaces seemed clean and odour free
Fridge/ freezer/ Cooker – clean/ are they free from dirt, odour / Fridge and freezer is clean and free of dirt
Expiry dates of food – a random sample to be checked / 2 items checked to be within expiry date deadline – other food items with no packaging or expiry dates – fruit and veg
Open food- Resealed and labelled with the date open. a random sample to be checked (include fridge/ freezer) / No open food seen apart from food being prepared at the time
Food hygiene corticated displayed (ideally displayed by the entrance) / Displayed in kitchen area
Fridge/ freezer temperatures recorded / Small folder records regular fridge temperatures 2 times daily
Does the home have enough food supply? Includes fresh food, vegetables / Viewed store which contained fresh food supplies – deliveries occur 2 times weekly or when required
COSHH
Is the cleaning cupboard a locked? / Yes
Are there any unlabelled bottles? / None viewed
Does the home holds COSHH information/ leaflets for the cleaning chemicals used in the home / Yes
Pets
Does the home allow pets? / No current pets but would be welcome
Do you currently have pets? / No
Who pays for the Vet bills/ insurance etc. / N/A
Vaccination and Insurance up to date / N/A
- STAFF AND VOLUNTEERS
Staff Recruitment -10% of the total no of staff files to be evidenced. Please include a mixture of management, bank, volunteers and permanent staff.
Topic / Please tick (Y/N) / Comments
- Application form
- Two References and validated by the provider
- Proof of photographic ID and validated by the provider that it’s a true likeness
- Proof of Address and validated by the provider
- Up-to-date Disclosure Barring Service (DBS)evidence in file. (Remind good practice review DBS 3 yearly)
- Staff Contract available - dated and signed by the employee
- Job description
- Right to work documentation validated an available in the file e.g. work permit, visa, NI number
- Nursing and Midwifery Council (if nursing home)
- Previous job related qualification evidenced
- Induction completed and dated/ signed
- Interview question details- Remind this is good practice.
Staff training - 10% of the total no of staff files to be evidenced. Please include a mixture of management, bank, volunteers and permanent staff.
Medicines management / yes
Infection control
Dementia
End of life care / Yes
Mental Capacity Act (MCA) and Deprivation of Liberties Safeguards (DoLS) / yes
Safeguarding adults processes and who to refer to, host authority
Health and Safety / Yes
Food hygiene & nutrition
Moving and Handling
Fire / yes
First Aid
Specialist training (for Learning Disability/ Mental Health homes. This may include some home specialising dementia & sensory impairment)
Autism
Sensory impairment (including people who are deaf/blind)
For people who challenge, Positive Behaviour Support and Safe, diffusion and Intervention / yes / Closely related training on challenging behaviour
Recognise and manage risks effectively, whilst maximising independence through encouraging and facilitating positive risk taking
CPA approach; and an understanding of the step-down and recovery model within mental health services
Evidence of a rolling programme of continuous learning and personal development / yes / Programme of training ongoing during the year
Staff supervisions & Appraisals- 10% of the total no of staff files to be evidenced. Please include a mixture of management, bank, volunteers and permanent staff.
Evidence of minimum SIX supervisions per year / yes / Staff receive training every 3 months
Annual appraisals / 1 appraisal session held each year
Evidence of follow ups on actions identified in supervisions/ appraisals / Recorded in staff folders any comments, items discussed and actions. Comments include training recommendations and regular updates by manager
- POLICIES AND PROCEDURE
Name of the policy / Last review date
(best practise to review at least 3 yearly or when changes occur in the Law) / Any actions /Comments
Health and Safety / yes
Staff code of conduct or equivalent
Manual handling / yes
Pressure care management / Yes
Nutrition and feeding techniques (including dysphagia management)
Dementia care
Medicines management / Yes
Infection control
End of life care (including communication and dealing with bereavement and loss)
Positive behaviour management and safe intervention
Safeguarding / Yes
DOLS, MCA, MH Act and S117 duties, Care Act duties / yes
Complaints procedure
Grievance / disciplinary procedures
Whistle blowing policy / yes
Confidentiality
Dignity and respect declaration
Equality & Diversity
Care planning & risk management
Finance / yes
Gifts
Supervision & Appraisal
Fire / yes
Staff Recruitment
Volunteers
Quality Assurance
Business continuity
Accident & Emergency
Lone working
CCTV
Bullying & Harassment / yes
- CLIENTS MONETARY AFFAIRS / GRATUITIES/ FINANCE MANAGEMENT
Topic / Please tick (Y/N)
Does the Provider undertake any financial transactions on behalf of service users? / Yes
Evidence what systems are in place to record transaction
Petty cash system in place to manage individual residents personal monies for toiletries etc
Evidence how the Provider conveys this to Care Workers
Staff will sign to confirm they are aware of the processes
Does the home provides a secure mechanism to safe keep individuals valuables e.g. cash, jewellery, etc. / [Withheld – Prevention of Crime]
Does home operates a petty cash system / yes
Robust documentation of Petty cash management / Yes – all transactions are recorded to show monies going in and out
Other